EVERYTHING UNDER THE SUN

Question 1

Excellent marker of the insulin-resistant condition in metabolic syndrome?

a.
Hyperglycemia

b.
Hypertension

c.
Hypertriglyceridemia

d.
Hyperuricemia

Answer 1

C

Answer: C. Hypertriglyceridemia

Source: HPIM 21st ed, Ch. 408, p. 3153

Hypertriglyceridemia is an excellent marker of the insulin-resistant condition.
Hyperuricemia reflects defects in insulin action on the renal tubular reabsorption of uric acid and may contribute to hypertension through its effect on the endothelium.
In the setting of insulin resistance, the vasodilatory effect of insulin is lost but the renal effect on sodium reabsorption is preserved. Insulin also increases the activity of the sympathetic nervous system, an effect that is preserved in the setting of insulin resistance.
The correct answer is: Hypertriglyceridemia

Question 2

42-year-old female came into the Endocrinology outpatient clinic for consultation. She also expressed the desire to be screened for obesity and its associated conditions. On physical examination, her BMI was 26 kg/m2, her waist circumference was 85cm, and her waist-hip ratio was 0.90. Which of the following is NOT an appropriate recommendation for this patient?

a.
Recommend screening for depression using Patient Health Questionnaire-9 every 6 months

b.
Recommend screening for dyslipidemia using fasting lipid profile

c.
Recommend screening for osteoarthritis using x-ray yearly

d.
Recommend screening for polycystic ovarian syndrome using Rotterdam criteria

Answer 2

C

Using the American College of Rheumatology Clinical Criteria for osteoarthritis every visit

Question 3

Which of the following statements regarding lifestyle management for obesity is TRUE?

a.
A calorie deficit of 100 kcal/day is consistent with a goal of losing ~1-2 lb/week.

b.
The most important role of exercise is in the achievement of weight loss.

c.
Around >300 minutes of moderate-intensity activity per week is often needed to lose weight and sustain weight loss.

d.
Weight loss depends primarily on reductions of specific proportions of carbohydrates, fats, and proteins.
Feedback
Answer: C. Around >300 minutes of moderate-intensity activity per week is often needed to lose weight and sustain weight loss.

Source: HPIM 21st ed, Ch. 402, p. 3090-3091

A high level of physical activity (>300 minutes of moderate-intensity activity per week) is often needed to lose weight and sustain weight loss.
Adults should engage in 150 minutes of moderate-intensity or 75 minutes a week of vigorous-intensity aerobic physical activity per week, preferably spread throughout the week.
The most important role of exercise is in the maintenance of weight loss.
The correct answer is: Around >300 minutes of moderate-intensity activity per week is often needed to lose weight and sustain weight loss.

Answer 3

Answer: C. Around >300 minutes of moderate-intensity activity per week is often needed to lose weight and sustain weight loss.

Source: HPIM 21st ed, Ch. 402, p. 3090-3091

A high level of physical activity (>300 minutes of moderate-intensity activity per week) is often needed to lose weight and sustain weight loss.
Adults should engage in 150 minutes of moderate-intensity or 75 minutes a week of vigorous-intensity aerobic physical activity per week, preferably spread throughout the week.
The most important role of exercise is in the maintenance of weight loss.
The correct answer is: Around >300 minutes of moderate-intensity activity per week is often needed to lose weight and sustain weight loss.

Question 4

Which of the following insulin resistance syndromes affect middle-aged women and is characterized by severe hyperinsulinemia, features of hyperandrogenism, and autoimmune disorders?

a.
Type A insulin resistance syndrome

b.
Type B insulin resistance syndrome

c.
Polycystic ovary syndrome

d.
Lipodystroph

Answer 4

B

Type A insulin resistance syndrome affects young women and is characterized by severe hyperinsulinemia, obesity, and features of hyperandrogenism. This is usually due to an undefined defect in insulin-signaling pathway
Type B insulin resistance syndrome affects middle-aged women and is characterized by severe hyperinsulinemia, features of hyperandrogenism, and autoimmune disorders. These patients have autoantibodies directed at the insulin receptor.
Polycystic ovary syndrome affects premenopausal women and is characterized by chronic anovulation and hyperandrogenism.
Lipodystrophies are characterized by selective loss of adipose tissue, leading to severe insulin resistance, and hypertriglyceridemia.

Question 5

hich of the following statements regarding the ophthalmologic complications of diabetes is TRUE?

a.
Aspirin therapy delays progression of diabetic retinopathy.

b.
Lowering elevated levels of triglycerides with fenofibrate may reduce progression of retinopathy

c.
Routine, nondilated eye examinations by the primary care provider or diabetes specialist are adequate to detect diabetic eye disease.

d.
The most effective therapy for diabetic retinopathy is glucose control.

Answer 5

Feedback
Answer: B. Lowering elevated levels of triglycerides with fenofibrate may reduce progression of retinopathy.

Source: HPIM 21st ed, Ch. 405, p. 3122

Routine, nondilated eye examinations by the primary care provider or diabetes specialist are inadequate to detect diabetic eye disease, which requires a dilated eye exam performed by an optometrist or ophthalmologist, and subsequent management by a retinal specialist.
The most effective therapy for diabetic retinopathy is prevention, not glucose control.
Once advanced retinopathy is present, improved glycemic control imparts less benefit, although adequate ophthalmologic care can prevent most blindness.
Aspirin therapy (up to 650 mg/d) does not appear to influence the natural history of diabetic retinopathy, and antiplatelet agents and anticoagulation may be continued in patients receiving intravitreal injections of anti-VEGF agents.
The correct answer is: Lowering elevated levels of triglycerides with fenofibrate may reduce progression of retinopathy

Question 6

What is the most common pattern of dyslipidemia in patients with diabetes mellitus?

a.
Elevated LDL, low HDL

b.
Elevated triglycerides, low HDL

c.
Elevated total cholesterol, elevated LDL

d.
Elevated triglycerides, elevated LDL

Answer 6

B

Question 7

A 54 year-old female with obstructive sleep apnea came into the weight management center for weight loss advice and management. Her initial BMI was 40 kg/m2, and comprehensive lifestyle intervention was initiated with pharmacotherapy. However, on follow-up, weight loss was only 2% and there was no improvement in health targets. Hence, she was referred to a bariatric surgeon and subsequently underwent a Roux-en-Y gastric bypass. Post-operatively, she experienced dramatic weight loss, but complained of prolonged nausea and vomiting of undigested food after eating. What is the best next step in the management of this patient?

a.
Advise that this is an expected effect of the bypass surgery

b.
Initiate folic acid supplementation

c.
Refer patient for re-operation

d.
Refer patient for endoscopy

Answer 7

D

Answer: D. Refer patient for endoscopy

Source: HPIM 21st ed, Ch. 402, p. 3094

The most common surgical complications include stomal stenosis or marginal ulcers (occurring in 5-15% of patients) that present as prolonged nausea and vomiting after eating or inability to advance the diet to solid foods.
These complications typically are treated by endoscopic balloon dilation and acid suppression therapy, respectively.
Restrictive-malabsorptive procedures require lifelong supplementation with vitamin B12, iron, folate, calcium, and vitamin D.
The correct answer is: Refer patient for endoscopy

Question 8

A 36-year-old patient with type 1 diabetes DM is started on combination of insulin glargine and insulin aspart. You instructed him regarding the insulin-to-carbohydrate ratio so that he can adjust his pre-prandial insulins. He reported that today, his pre-lunch CBG is 200 mg/dL. What is the correct advice?

a.
Increase dose of insulin aspart by 2 units

b.
Increase dose of insulin glargine by 5 units

c.
Increase dose of insulin aspart by 4 units

d.
No adjustment necessary

Answer 8

A

Question 9

A 38-year-old hypertensive female consulted at the outpatient clinic for a general check-up. She had a BMI of 27 kg/m2 and a waist circumference of 87cm. She complained of daytime sleepiness and amenorrhea for 3 months. Physical examination showed central obesity and significant hair growth in the upper back and upper arms. Which of the following is NOT an appropriate next diagnostic test in the evaluation of this patient?

a.
Fasting lipids

b.
Liver elastography

c.
Overnight polysomnography

d.
Serum testosterone

Answer 9

B

The diagnosis of the metabolic syndrome relies on the fulfillment of the harmonizing definition, assessed using bedside measurements and diagnostic tools.
Measurement of fasting lipids and glucose is needed in determining whether metabolic syndrome is present. The measurement of additional biomarkers associated with insulin resistance can be individualized. Such tests might include those for apoB, hsCRP, fibrinogen, uric acid, urinary albumin/creatinine ratio, and liver function.
A sleep study should be performed if symptoms of obstructive sleep apnea are present.
If polycystic ovary syndrome is suspected based on clinical features and anovulation, testosterone, luteinizing hormone, and follicle-stimulating hormone should be measured.
Liver elastography is the best answer in this item. Although NAFLD can be further assessed by the NAFLD fibrosis score or elastography, the diagnosis of NAFLD is not established in this case based on the clinical details presented, hence initial evaluation using a liver ultrasound would be indicated first to establish the diagnosis of NAFLD.
The correct answer is: Liver elastography

Question 10

Which among the statements is TRUE in the hormonal evaluation of patients with hirsutism?

a.
A testosterone level >7 nmol/L (>2ng/mL) is suggestive of a tumor but may also be observed in women with hyperthecosis.

b.
A basal DHEAS >18.5umol/L (>7000 ug/L) suggests a pituitary tumor.

c.
An increased ratio of FSH to LH is characteristic in carefully studied patients with polycystic ovary syndrome.

d.
An modestly elevated DHEAS is an unusual finding among women with polycystic ovary syndrome.

Answer 10

A

Question 11

Which of the following etiologies of hypercalcemia is CORRECTLY matched with its mechanism?

a.
Familial hypocalciuric hypercalcemia: abnormal sensing of blood calcium by the parathyroid gland and renal tubule leading to increased bone turnover

b.
Lithium therapy: stimulation of parathyroid cell replication and shifting of parathyroid hormone (PTH) secretion curve to the right in response to calcium

c.
Malignancy-related hypercalcemia: increased synthesis of excess 1, 25(OH)2D by malignant cells

d.
Vitamin D-related hypercalcemia: increased intestinal Vitamin D absorption and decreased calcium incorporation into bone

Answer 11

Answer: B. Lithium therapy: stimulation of parathyroid cell replication and shifting of parathyroid hormone (PTH) secretion curve to the right in response to calcium

Source: HPIM 21st ed, Ch. 410, p. 3178-3179

The mechanism of FHH is from an inactivating mutation in a single allele of the CaSR. The primary defect is abnormal sensing of blood calcium by the parathyroid gland and renal tubule, causing inappropriate PTH secretion and excessive calcium reabsorption in the distal renal tubules.
Malignancy-related hypercalcemia: production and secretion of PTHrP, or through direct bone marrow invasion
Vitamin D-related hypercalcemia: increased intestinal calcium absorption and increased release from bone
The correct answer is: Lithium therapy: stimulation of parathyroid cell replication and shifting of parathyroid hormone (PTH) secretion curve to the right in response to calcium

Question 12

You are prescribing your patient with alendronate for her osteoporosis. Which is an appropriate advice that can be given to the patient?

a.
Take alendronate with a full glass of milk

b.
Take alendronate after an overnight fast

c.
Crush alendronate to avoid pill esophagitis

d.
Remain upright for 10 minutes after taking the medication

Answer 12

B.

Remain at least 30 min upright after taking alendronate, not 10 min.
Contraindicated in Esophageal strictures

Question 13

A 45 year-old male was referred to you for hypercalcemia. On evaluation, he had a serum calcium of 10.9 mg/dL (NV 8-10 mg/dL). Creatinine clearance was 65 mL/min, and there was no nephrolithiasis or any vertebral fractures on radiologic examinations. Bone mineral density by DXA was -2.0. Patient is otherwise asymptomatic and the rest of the evaluation was unremarkable. What clinical features warrant surgery in this patient?

a.
Age

b.
Bone mineral density

c.
Creatinine clearance

d.
Surgery is not indicated in this patient

Answer 13

A

<50
T score <-2.5
PResence of fractures
Serum Calcium >1 mg/dl
Creatinine clearance <60
24 Hr urine calcium >400 mg/dl/Nephrocalcinosis

Question 14

what are the basic tests for the initial hormonal evaluation for patients suspected for pituitary adenoma on MRI?

Answer 14

When a pituitary adenoma is suspected based on MRI, initial hormonal evaluation usually includes:

(1) basal prolactin (PRL)
(2) insulin-like growth factor (IGF)-1
(3) 24-h urinary free cortisol (UFC) and/or overnight oral dexamethasone (1 mg) suppression test
(4) alpha-subunit follicle-stimulating hormone (FSH), and luteinizing hormone (LH)
(5) thyroid function tests

Additional hormonal evaluation may be indicated based on the results of these tests.

Question 15

Which among the following statements in the treatment of subacute thyroiditis is TRUE?

a.
Antithyroid drugs aid in symptom control and treatment during the thyrotoxic phase.

b.
Relatively small doses of aspirin or NSAIDs are sufficient to control symptoms in many cases.

c.
Glucocorticoids should be given if patients have marked local or systemic symptoms.

d.
LT4 replacement is not needed in the hypothyroid phase of the illness.

Answer 15

C

Question 16

Your 43-year-old male patient with hypothyroidism came to your clinic for follow-up. On evaluation, you noted that his TSH is still elevated despite adequate doses. He admitted that he often misses doses due to his busy schedule and even missed his dose today. He is asking what to do now with his skipped dose. What is the most appropriate advice?

a.
Ask him to get a serum FT4 and recompute dosing based on the FT4 result.

b.
Double the dose for the following week, then return to original dosing afterwards.

c.
Take two doses of the skipped tablets at once.

d.
Take the intended dose for that day only and forget the skipped dose.

Answer 16

Answer: C. Take two doses of the skipped tablets at once.

Source: HPIM 21st ed, Ch. 383, p. 2937

Elevated TSH in patients with >200mcg/d is a sign of poor adherence. Some have normal or high unbound FT4, despite elevated TSH since they remember to take medications a few days before testing.
Patients who miss a dose can be advised to take two doses of skipped tablets at once due to the long half-life of T4.
The correct answer is: Take two doses of the skipped tablets at once.

Question 17

evothyroxine therapy is indicated for patients with thyroid cancer since most tumors are still TSH-responsive. What range of TSH should be targeted in patients at intermediate risk of recurrence?

a.
< 0.1 mIU/L

b.
0.1 – 0.5 mIU/L

c.
0.5 – 2 mIU/L

d.
2.5 – 5 mIU/

Answer 17

B

TSH suppression therapy targets for thyroid cancer:

Low risk of recurrence:
0.5-2.0 mIU/L
Intermediate risk of recurrence:
0.1-0.5 mIU/L

High risk of recurrence: <0.1 mIU/L

Known metastatic disease: <0.1 mIU/L

Question 18

hich of the following is the correct sequential order of hormone loss in acquired pituitary hormone deficiency?

a.
GH → TSH → ACTH → LH/FSH

b.
GH → TSH → LH/FSH → ACTH

c.
GH → LH/FSH → TSH → ACTH

d.
GH → LH/FSH → ACTH → TSH

Answer 18

C

“Ga La Ta Aa na ang Pituitary Gland”

Question 19

A 28-year-old female consulted your clinic because of blurring of vision. On physical examination, you noted bitemporal hemianopsia. Work up revealed a prolactin level of 956 ng/uL (N: 0-15 ng/uL). An MRI of the brain revealed a 12-mm pituitary tumor. Cabergoline was initiated in this patient. within how many weeks of initial therapy should cranial MRI be repeated to assess adenoma size?

Answer 19

16 weeks

Question 20

hat results in the adrenal vein sampling will warrant a left adrenalectomy?

a.
aldosterone/cortisol ratio 1.5 times higher on left adrenal vein vs. right adrenal vein

b.
aldosterone/cortisol ratio 3 times higher on left adrenal vein vs. right adrenal vein

c.
cortisol gradient > 3 on left adrenal vein

d.
cortisol gradient > 3 on right adrenal vein

Answer 20

B

Selective adrenal vein sampling (AVS) should only be carried out in surgical candidates with either no obvious lesion on CT or evidence of a unilateral lesion but with age >40 years because the latter patients have a high likelihood of harboring a coincidental, endocrine-inactive adrenal adenoma.
AVS is used to compare aldosterone levels in the inferior vena cava and between the right and left adrenal veins. AVS requires concurrent measurement of cortisol to document correct placement of the catheter in the adrenal veins and should demonstrate a cortisol gradient >3 between the vena cava and each adrenal vein.
Lateralization is confirmed by an aldosterone/cortisol ratio that is at least twofold higher on one side than the other.
An aldosterone/cortisol ratio that is 3x higher on the left adrenal vein vs. the right adrenal vein confirms the left adrenal mass as the cause of the aldosterone oversecretion.

Question 21

A 46 year old male came in your clinic due to progressive sharply demarcated intensely erythematous plaques with secondary pustules and scaling, initially started in the palms and soles before progressing to his arms and legs. He also reported undocumented febrile episodes. He recently used an unrecalled topical skin care product recommended by a friend. What is the best management of choice?

a.
Topical glucocorticoids

b.
Oral glucocorticoids

c.
Oral retinoids

d.
Oral antibiotics

Answer 21

C

this is pustular psoriasis

Question 22

40 year old male initially presented with cough and fever, and was given Cotrimoxazole by a local physician. He eventually developed high grade fever, sore throat, conjunctivitis, oral ulcerations, and acute onset of painful dusky, atypical, target-like lesions of hands and feet, eventually progressing of abdomen and bilateral legs with 40% desquamation. What is the best management for this case?

a.
Supportive management

b.
Early administration of systemic glucocorticoids

c.
Intravenous immunoglobulin

d.
Cyclosporine

Answer 22

A

this is a case of TEN

Question 23

Which patient with psoriasis SHOULD NOT receive phototherapy?

a.
26 year old male taking Methotrexate

b.
30 year old female on Cyclosporine

c.
40 year old female on Apremilast

d.
43 year old male on Acitretin

Answer 23

B

Question 24

What is the single most important bedside measurement to estimate the volume status of the patient?

a.
Blood pressure

b.
Capillary refill time

c.
Heart rate

d.
Jugular venous pressure

Answer 24

D

Question 25

What configuration of premature ventricular contractions are most likely to be associated with structural heart disease?

a.
Left bundle branch block configuration

b.
Right bundle branch block configuration

c.
Unifocal morphology

d.
The morphology of PVCs are not suggestive of the presence of any underlying heart disease.

Answer 25

B

ECG characteristics can be suggestive of presence of structural heart disease.
PVCs with an RBBB configuration more likely to be associated with structural heart disease

Multifocal PVCs more likely to indicate structural heart disease or myopathic disease

Most common arrhythmias not associated with heart disease have LBBB configuration

The correct answer is: Right bundle branch block configuration

Question 26

what is the mechanism of TDP? (ventricular arrythmia?

a. Accelerated phase 4 repolarization

b. Delayed after depolarizations

c. Early afterdepolarizations

d. Suppressed phase 4 repolarization

Answer 26

C

Question 27

Among the narrow complex tachycardias, which will not present with a 1:1 AV response?

a.
Atrial flutter

b.
AV nodal reentrant tachycardia (AVNRT)

c.
Junctional tachycardia

d.
Orthrodromic reciprocating tachycardia (ORT)

Answer 27

A

Question 28

What defines adequate rate control in patients with atrial fibrillation?

a.
A resting heart rate of <80bpm that increases to <100bpm with light exertion.

b.
A resting heart rate of <70bpm that increases to <100bpm with light exertion.

c.
A resting heart rate of <80bpm that increases to <110bpm with light exertion.

d.
A resting heart rate of <70bpm that increases to <110bpm with light exertion.

Answer 28

A

Question 29

A 83-year-old female is referred for preoperative evaluation prior to a total knee replacement. On examination, you noted an irregularly irregular heart rate with a full minute heart rate of 107. An ECG you subsequently ordered showed Atrial Fibrillation.

Upon review of her medical records, she had no previous history of irregular heart rhythm, and her last ECG 5 years ago showed sinus rhythm. Relatives were also unaware if the patient had any similar episodes detected recently. What is the best treatment option for this patient’s abnormal rhythm?

a.
Initiate electrical cardioversion immediately to convert to sinus rhythm.

b.
Initiate anticoagulation and perform a TEE. If a thrombus is absent, perform cardioversion and discontinue anticoagulation afterwards.

c.
Initiate anticoagulation continuously for 3 weeks before and at least 4 weeks after cardioversion.

d.
Start propranolol for rhythm control.

Answer 29

C

Question 30

In patients with symptomatic HFrEF who are being transitioned to an angiotensin receptor/neprilysin inhibitor from an ACE inhibitor, how many hours is the recommended gap to limit the risk of overlap?

Answer 30

36 hrs

Question 31

What is the most common cause of restrictive cardiomyopathy?

Answer 31

Amyloidosis

Question 32

In the evolution of electrocardiogram findings in acute pericarditis, the inversion of T waves are found in which stage?

a.
Stage 1

b.
Stage 2

c.
Stage 3

d.
Stage 4

Answer 32

C.

ECG changes in acute pericarditis evolve through four stages
Stage 1: widespread elevation of the ST segments, often with upward concavity, involving two or three standard limb leads and V2-V6 with reciprocal depressions only in aVR and occasionally V1 with accompanying PR depression representing atrial involvement
Stage 2: ST segments return to normal
Stage 3: T waves become inverted
Stage 4: ECG returns to normal
The correct answer is: Stage 3

Question 33

Which of the following adjunctive treatments in heart failure can lead to improvement in patients’ sense of wellbeing and show a trend toward mortality reduction?

a.
Enhanced external counterpulsation

b.
Long-chain omega-3 polyunsaturated fatty acids

c.
Sertraline therapy

d.
Supervised exercise training

Answer 33

D.

HF-ACTION STUDY

Question 34

A 65-year-old female with heart failure was admitted at the emergency room for progressive dyspnea. She was eventually assessed as a case of acute decompensated heart failure. Among these physical examination and laboratory parameters, which is associated with worse outcomes?

a. Blood pressure of 120/80 mmHg

b. Blood urea nitrogen level of 15.7 mmol/L

c. Normal cardiac troponin

d. Serum creatinine of 234 umol/L

Answer 34

b.

Parameters associated with worse outcomes among inpatients with ADHF are the following:
blood urea nitrogen level >43 mg/dL (to convert to mmol/L, multiply by 0.357) OR 15.35 MMOL/L

systolic blood pressure <115 mmHg

serum creatinine level >2.75 mg/dL (to convert to umol/L, multiply by 88.4) OR 243.1 MMOL/L

elevated cardiac biomarkers including natriuretic peptides and cardiac troponins.

The correct answer is: Blood urea nitrogen level of 15.7 mmol/L

Question 35

45-year-old 90-kg female presents with a 4-day history of unremitting substernal chest pain radiating to the left shoulder. The pain is worse when she is lying down and improves when she leans forward. 12L ECG shows diffuse ST elevations with upward concavity. Which of the following should be given to this patient as part of treatment?

a. Aspirin 4g daily

b.
Colchicine 0.5mg/tab once daily

c.
Early ambulation

d.
Metoclopramide 10 mg every 8 hours

Answer 35

a.

Colchicine dose in this case is not appropriate since she is 90 kg. it should be 0.5 mg BID

Question 36

Hypokalemia and hypomagnesemia are risk factors for ventricular fibrillation in patients with STEMI.

To reduce the risk, the serum potassium concentration should be adjusted to ______ mmol/L and magnesium to ____ mmol/L.

Answer 36

Serum K 4.5
Serum Mg 2

Question 37

2020 PSH CPG (HYPERTENSION)

For the very elderly, defined as 80 years old and above, a therapeutic threshold of _____ mmHg to achieve a goal BP of less than _____ mmHg is recommended.

A therapeutic threshold of ____ mmHg to achieve a goal BP of less than_____ mmHg is recommended for most adults with hypertension.

Answer 37

150/90
140/90

140/90
130/80

Question 38

Which of the following would warrant discontinuation of a treadmill exercise test?

a. Development of an atrial tachyarrhythmia

b. Fall in systolic blood pressure >15 mmHg

c. Mild shortness of breath

d. ST-segment depression >0.2mV

Answer 38

D.

The most widely used test for both the diagnosis of IHD and the estimation of risk and prognosis involves recording of the 12-lead ECG before, during, and after exercise, usually on a treadmill

The test is discontinued upon evidence of:
1. chest discomfort
2. severe shortness of breath
3. dizziness
4. severe fatigue
5. ST-segment depression >0.2 mV (2 mm)
6. a fall in systolic blood pressure >10 mmHg
7. development of a ventricular tachyarrhythmia

The correct answer is: ST-segment depression >0.2mV

Question 38

A 43-year-old female with breast cancer presented at the ER with left leg pain after being bedridden for 5 days from severe dizziness from recent whole brain radiotherapy. On examination, there is entire left leg swelling measuring 2.5 cm greater than the right calf. No collateral superficial veins nor edema were noted but the midline part of the back of the left leg is tender to touch. What is the Wells score and the clinical likelihood of the patient for deep vein thrombosis?

a.
2, moderate likelihood

b.
3, moderate likelihood

c.
4, high likelihood

d.
5, high likelihood

Answer 38

c

Question 39

75-year-old female with breast cancer was brought to the ER due to sudden onset of hemoptysis and dyspnea. There were no current signs and symptoms of DVT and the patient was ambulatory prior. Her vitals were as follows: blood pressure of 90/60 mmHg, heart rate of 120 bpm, respiratory rate of 26 cpm, and an oxygen saturation of 92% on room air. The patient was not able to tolerate intravenous contrast, and a lung scan showed one segmental perfusion defect in the presence of normal ventilation. What is the next best step in pursuing the diagnosis for the patient’s dyspnea?

a.
Stop, pulmonary embolism is confirmed

b.
Perform invasive pulmonary angiography

c.
Perform transthoracic echocardiography

d.
Perform venous ultrasound

Answer 39

d

1ST LINE: CHEST CT
2ND LINE: LUNG SCANNING
(NEED 2 OR MORE SEGMENTAL PERFUSION DEFECT WITH NORMAL VENTILATION)

Question 40

refers to intrahepatic cholestasis specifically associated with renal cell cancer:

a.
Castleman Syndrome

b.
Kiramman Syndrome

c.
Stauffer’s Syndrome

d.
Zieve’s Syndrome

Answer 40

c

Question 41

Most common esophageal symptom:

Answer 41

pyrosis

Question 42

The most sensitive test for diagnosis of gastroesophageal reflux disease (GERD) is

Answer 42

24-h ambulatory pH monitoring.

Question 43

alarm symptoms for gerd (3)

Answer 43

such as dysphagia, weight loss, or gastrointestinal bleeding;

Question 44

Which of the following medications for peptic ulcer disease is LEAST likely to cause diarrhe?

a.
Misoprostol

b.
Bismuth

c.
Magnesium hydroxide

d.
Proton pump inhibitor

Answer 44

B

Question 45

Which of the following breast cancer molecular features is correctly matched to their associated targeted therapies?

a.
Estrogen receptor: Leuprolide for postmenopausal women

b.
HER2: Lapatinib

c.
mTOR: PARP inhibitors

d.
BRCA 1/2: Everolimus

Answer 45

B

Question 46

Which of the following types has the poorest prognosis?

a.
Luminal A tumors

b.
Luminal B tumors

c.
Basal breast cancers

d.
HER2-like tumors

Answer 46

C

also called “triple negative”

luminal A- most favorable prognosis

Question 47

Which of the following is a major contraindication to surgical resection of a resectable lung tumor?

a.
FEV1 of less than 1 L

b.
Myocardial infarction in the past 6 months

c.
Resting Pco2 43 mmHg

d.
DLcO of 40%

Answer 47

A.

Patients with a forced expiratory volume in 1 s (FEV1) of >2 L or >80% of predicted can tolerate a pneumonectomy, and those with an FEV1 >1.5 L have adequate reserve for a lobectomy.

A myocardial infarction within the past 3 months is a contraindication to thoracic surgery because 20% of patients will die of reinfarction.

An infarction in the past 6 months is a relative contraindication.

Other major contraindications include uncontrolled arrhythmias, an FEV1 of <1 L, CO2 retention (resting Pco2 >45 mmHg),
DLco <40%, and
severe pulmonary hypertension.

Question 48

Which of the following statements is TRUE regarding polyps?

a.
Tubulovillous adenomas, most of which are sessile, become malignant more than three times as often as tubular adenomas.

b.
Invasive cancers develop more frequently in pedunculated, adenomatous polyps.

c.
The likelihood that any polypoid lesion in the large bowel contains invasive cancer is related to the size of the polyp

d.
Once an adenomatous polyp is detected, flexible sigmoidoscopy should be repeated periodically even in the absence of a previously documented malignancy

Answer 48

C.

Villous adenomas, most of which are sessile, become malignant more than three times as often as tubular adenomas.
The likelihood that any polypoid lesion in the large bowel contains invasive cancer is related to the size of the polyp, being negligible (<2%) in lesions <1.5 cm, intermediate (2–10%) in lesions 1.5–2.5 cm, and substantial (10%) in lesions >2.5 cm in size.
Invasive cancers develop more frequently in sessile, serrated (i.e., “flat”) polyps.
Following the detection of an adenomatous polyp, the entire large bowel should be visualized endoscopically because synchronous lesions are noted in about one-third of cases. Colonoscopy should then be repeated periodically, even in the absence of a previously documented malignancy, because such patients have a 30–50% proba- bility of developing another adenoma and are at a higher-than-average risk for developing a colorectal carcinoma
The correct answer is: The likelihood that any polypoid lesion in the large bowel contains invasive cancer is related to the size of the polyp

Question 49

Which is TRUE regarding surveillance of colorectal cancer after complete resection?

a.
Colonoscopy every 3 years

b.
CT scan of the abdomen annually for the first 5 postoperative years

c.
Measure plasma CEA levels at 6-month intervals

d.
CT scan of the chest annually for surveillance for metastasis

Answer 49

A

CT scan of the abdomen annually for the first 5 postoperative years- annually for 3 years

c.
Measure plasma CEA levels at 6-month intervals- 3 months interval

d.
CT scan of the chest annually for surveillance for metastasis- not recommended

Question 50

chemotherapy drug can cause Raynaud’s phenomenon?

a.
Cisplatin

b.
Docetaxel

c.
Etoposide

d.
Gemcitabine

Answer 50

A.

Question 51

A 52 year old female is being evaluated for anemia in her routing laboratory work-up, with a Hgb of 102 g/L. Her work-up showed the following: serum ferritin 18 ug/L, TIBC 370 ug/dL, serum iron 100 ug/L. What is the stage of her iron deficiency?

a.
Normal

b.
Negative iron balance

c.
Iron deficient erythropoiesis

d.
Iron deficiency anemia

Answer 51

B.

D: RBC becomes micro, hypo

Question 52

Which of the following parameters is more consistent with iron deficiency anemia?

a.
Elevated protoporphyrin level

b.
Decreased total iron-binding capacity

c.
Elevated serum ferritin

d.
Decreased transferrin receptor protein (TRP)

Answer 52

a

Question 53

Which of the following is correct regarding β thalassemia?

a.
Gene deletions are the most common mutations

b.
Plasmodium falciparum infection is a risk factor for developing complications forms for β thalassemia

c.
Secondary infection is the most common complications of the disease

d.
Management include transfusion every 2–4 weeks with a goal pretransfusion hemoglobin of 9–10.5 g/dL with oral chelation

Answer 53

D

Question 54

What is the most evident symptom among patients CKD stages 3-4?

a.
Decreased appetite

b.
Easy fatigability

c.
Vomiting

d.
Edema

Answer 54

b.
Easy fatigability

anemia with easy fatiguability

Question 55

What is the most frequent cause of CKD worldwide?

a.
Hypertension-associated CKD

b.
Glomerulonephritis

c.
Autosomal dominant polycystic kidney disease

d.
Diabetic nephropathy

Answer 55

D

Question 56

A 40 year old male came to your clinic due to elevated blood pressure. He usually takes Naproxen for his body pain from his work as a construction worker. His creatinine was 1.8 mg/dl with eGFR of 47 mL/min/1.73 m2, Na 134, K 5.0 mmol/L, HCO3 20.2 mmol/L, and proteinuria of 1.1g per 24h. He already had a kidney ultrasound showing renal parenchymal disease. His vital signs are as follows: BP 140/90 mmHg, HR 98 bpm, RR 18 bpm, and Temp 37.0 C. He showed you a BP recording a week ago of 150/90 mm Hg. He mentioned that his blood pressure during the previous years were normal. What is the first line therapy for controlling his blood pressure?

a.
Enalapril

b.
Amlodipine

c.
Carvedilol

d.
Salt restriction

Answer 56

D

Question 57

According to Harrisons Principle of Internal Medicine, what should be the target blood pressure of patients with CKD with proteinuria or diabetes?

a.
<140/90 mmHg

b.
<130/80 mmHg

c.
<120/80 mmHg

d.
<150/90 mmHg

Answer 57

B

Question 58

Which parameters are recommended for patients with CKD Stage 5 based on the KDIGO?

a.
Hemoglobin of 115-120 g/L

b.
Blood pressure of <140/90 mmHg

c.
PTH between 2 and 9 times upper limit of normal

d.
Oral fluid intake of <2.0 L per day

Answer 58

C.

Question 59

A 58 year old female came in your clinic due to an necrotic ulceration in her anterior abdomen which developed progressively from a small painful nodule. She is a known case of Heart Failure in Atrial Fibrillation, Hypertension, and CKD Stage 4, currently taking Sacubitril-Valsartan, Bisoprolol, Spironolactone, Dapagliflozin, Sodium Bicarbonate, Sevelamer, Calcium Carbonate, Warfarin, and Atorvastatin. Which drug is causing the said lesion?

a.
Dapagliflozin

b.
Sevelamer

c.
Spironolactone

d.
Warfarin

Answer 59

D

Thus, warfarin treatment is considered a risk factor for calciphylaxis, and if a patient develops this syndrome, this medication should be discontinued and alternative means of anticoagulation should be chosen…

(HPIM 21st ed, Ch 311, P 2314)

The correct answer is: Warfarin

Question 60

68 year old female was brought to the ER due to progressive edema and exertional dyspnea. She is a known hypertensive patient who irregularly takes Losartan and was lost to follow-up. On assessment, she is awake, not distress with BP 160/100 mmHg, HR 102 bpm, and RR 22 bpm, with noted neck vein distension, clear breath sounds, and grade 2 bipedal edema. Her laboratory results are as follows: Na 124 mEq/L, K 4.8 mEq/L, Cl 98 mEq/L, HCO3 22 mEq/L, BUN 10 mg/dL, creatinine 1.4 mg/dL. What is the best management for her hyponatremia?

a.
Furosemide

b.
Sodium Chloride Tablet

c.
Tolvaptan

d.
Desmopressin

Answer 60

A. Furosemide

this is hypervolemic hyponatremia from CHF
tx: treat underlying

Question 61

Reliable measures for volume depletion, except:

a. decreased jugular venous pressure (JVP), b. orthostatic tachycardia (an increase of >15–20 beats/min upon standing)
c. Orthostatic hypotension
(a >10–20 mmHg drop in blood pressure on standing)
d. none

Answer 61

D.

all are most reliable indicators

Question 62

Which of the following is NOT included in the risk factors for osmotic demyelination syndrome (ODS)?

a.
Alcoholism

b.
Malnutrition

c.
Hypokalemia

d.
Type 2 Diabetes Mellitus

Answer 62

D

Question 63

Which is the correct classical sequence of ECG progression in patients with progressively increasing hyperkalemia?

a.
Flat P waves > peaked T waves > widening of QRS > sine wave

b.
Loss of P waves > shortening of QRS > peaked T waves > sine wave

c.
Peaked T waves > widening of QRS > loss of P waves > sine wave

d.
Peaked T waves > loss of P waves > widening of QRS > sine wave

Answer 63

D

Classically, the ECG manifestations in hyperkalemia progress from
1. tall peaked T waves (5.5–6.5 mM),
2. Loss of P waves (6.5–7.5 mM)
3. widened QRS complex (7.0–8.0 mM)
4. sine wave pattern (>8.0 mM)

(HPIM 21st ed, Ch 53 P353)

The correct answer is: Peaked T waves > loss of P waves > widening of QRS > sine wave

Question 64

A 28 year old female was rushed in the ER due to a 3-day history of difficulty of breathing, generalized weakness and numbness of lips, hands, and feet. She is a known case of generalized anxiety disorder, currently taking Quetiapine. On assessment, she is awake, anxious, and tachypneic, BP is 130/80 mmHg, HR 110 bpm, RR 26 bpm, SpO2 97% on room air, with unremarkable physical examination. Her ABG showed pH 7.60, pCo2 20, pO2 103, HCO3 19. Which of the following is the most likely acid-base disorder in this patient?

a.
Respiratory alkalosis, compensated

b.
Metabolic acidosis with secondary respiratory alkalosis

c.
Respiratory alkalosis with secondary metabolic acidosis

d.
Metabolic acidosis, with secondary metabolic alkalosis

Answer 64

A.

Question 65

hich patient would urate-lowering therapy be MOST LIKELY recommended?

a.
A 30 year old male seeking consult due to first episode of painful, swollen right knee, with synovial fluid studies showing needle-shaped crystals with bright, negative birefringence under compensated polarized light

b.
A 30 year old female, known case of nephrolithiasis, admitted for treatment of UTI, with blood uric acid level of 9.0 mg/dL

c.
A 59 year old male patient, known hypertensive, hospitalized for decompensated heart failure with blood uric acid level of 10.0 mg/dL

d.
A 60 year old male seeking consult due to a bothersome lump on his left elbow, with bumpy, yellowish nodules just under the skin, with blood uric acid level of 6.0 mg/dL

Answer 65

D

Question 66

40 year old female relative asks for a second opinion regarding her uncontrolled asthma. She is already on high dose ICS-LABA daily with frequent reliever use, daily montelukast, and occasional oral corticosteroids for exacerbations about 2-3 times every year. She has been worked up before by her previous doctor and her laboratories show circulating IgE of 3 IU/mL and eosinophil count of 300/uL. What other pharmacologic option should be offered to the patient?

a.
Dupilumab

b.
Mepolizumab

c.
Omalizumab

d.
Zileuton

Answer 66

B

Omalizumab, a monoclonal antibody to the Fc portion of the IgE molecule, is used is circulating IgE is >= 30 IU/mL and if the patient has a positive skin test to a perennial allergen.

Page 2157

Question 67

20 year old male consults your clinic for persistent dry cough. He is a diagnosed asthmatic previously maintained on Salmeterol-fluticasone during childhood up to adolescent years but discontinue 2 years ago since he does not experience and symptoms anymore. For the past 2 months, he has been having daily bouts of dry cough and breathlessness causing him to awaken at night and preventing him from participating in school activities requiring physical endurance and fitness. On PE, the patient looks comfortable and speaks in sentences. You note his respiratory rate to be 16 while resting, heart rate of 89 and O2 saturation of 96% on room air. He also has occasional wheezing on all lung fields on auscultation. What is the recommended treatment regimen for this patient?

a.
Beclometasone-formoterol 100/6 mcg per actuation 2 actuations twice a day and 1 actuation as needed for reliever use

b.
Budesonide-formoterol 80/2.25mcg per actuation, 2 actuations twice a day and 1 actuation as needed for reliever use

c.
Budesonide-formoterol 80/2.25mcg per actuation, 4 actuations twice a day and 1 actuation as needed for reliever use

d.
Salmeterol-fluticasone 25/125mcg per actuation 2 actuations twice a day and 1 actuation of budesonide-formoterol 160/4.5mcg as needed for reliever use

Answer 67

A

Question 68

Which of the following toxic chemicals can cause ARDS after acute exposure with high amounts?

a.
Cadmium fumes

b.
Formaldehyde

c.
Ozone

d.
Sulfur dioxide

Answer 68

A.

B- chemical pneumonitis
C- Asthma exacerbation
D- bronchospasm

Question 69

The adequacy of alveolar ventilation is reflected in which parameter in the arterial blood gas?

a.
PaO2

b.
PaCO2

c.
SpO2

d.
TCO2

Answer 69

B

Question 70

Multiple pulmonary risk indices are available to estimate the postoperative risk of respiratory failure, pneumonia, and other pulmonary complications; among these is the Assess Respiratory Risk in Surgical Patients in Catalonia (ARISCAT) risk index which accounts for seven risk factors. Which of the following is NOT part of the risk factors scored in the ARISCAT Index?

a.
Hemoglobin < 10 g/dL

b.
Emergency surgery

c.
Presence of Type 2 Diabetes requiring insulin therapy

d.
Age

Answer 70

c.
Presence of Type 2 Diabetes requiring insulin therapy– Revised Cardiac Index ni siya

Question 71

Most blood-tinged sputum and small-volume hemoptysis are due to what etiology?

a.
Antiplatelet and anti-coagulant use

b.
Oropharyngeal irritation

c.
Vascular malformations

d.
Viral bronchitis

Answer 71

D.

Question 72

Among the pharmacologic therapies proven to aid in smoking cessation, this drug offers the highest cessation success compared to placebo:

a.
Bupropion

b.
Nicotine nasal inhaler

c.
Nortriptyline

d.
Varenicline

Answer 72

D

Question 73

Which of the following patients should be considered for bridging with High flow O2 or NIV post-extubation?

a.
A 60 year old patient

b.
A patient who is intubated for 5 days

c.
A patient with a BMI of 29

d.
A patient with an APACHE-II score of 15

Answer 73

A.

Age >65
>7 days intubated
BMI >30
CHF/COPD
APACHE score >12
>2 co-morbidities
Significant secretions

Question 74

Assessing weaning from mv:

a. Underlying process improved
b. FIO2 <0.3, PEEP <10
c. SaO2 >95%
d. BP 90/50

Answer 74

A.
Underlying process improving
FIO2 <0.3, PEEP <10
SaO2 >88%
Hemodynamically stable (OFF vasopressors)
awake, Minimal secretions, good cough

Question 75

A decrease in cerebral blood flow to <20/ml/100g tissue can cause death of brain tissue within how much time?

a.
Within 1-5 min

b.
Within 4-10 min

c.
Within an hour

d.
Within several hours or days

Answer 75

Answer: d.

b.
Within 4-10 min- if 0 blood flow

c.
Within an hour- 16-18 ml/100 g

Question 76

Which of the following is NOT a contraindication for intravenous recombinant tissue plasminogen activator (rtPA)?

a.
Bleeding diathesis

b.
Major surgery in the preceding 21 days

c.
Sustained BP >185/110 mmHg with treatment

d.
Gastrointestinal bleeding in preceding 21 days

Answer 76

B. Should be 14 days

add:
recent MI , head injury and intracerebral hemorrhage